The organizations below are mobilizing and deploying major disaster relief efforts. See how you can lend support, and check back for further updates.

World Food Programme
The UN’s hunger-fighting organization has allocated an immediate $2 million for Haiyan relief, with a greater appeal pending as needs become apparent. The UN organization is sending 40 metric tons of fortified biscuits in the immediate aftermath, as well as working with the government to restore emergency telecommunications in the area. Americans can text the word AID to 27722 to donate $10 or give online. Learn more here.

Red Cross
The humanitarian and disaster relief organization has sent emergency responders and volunteers to provide meals and relief items. Already, thousands of hot meals have been provided to survivors. Red Cross volunteers and staff also helped deliver preliminary emergency warnings and safety tips. Give by donating online or mailing a check to your local American Red Cross chapter. Learn more here.

AmeriCares
The emergency response and global health organization is sending medical aid for 20,000 survivors, including antibiotics, wound care supplies and pain relievers. AmeriCares is also giving funds to local organizations to purchase supplies. Learn more here.

World Vision
The Christian humanitarian organization that specifically supports families living in poverty is providing food, water and hygiene kits at the evacuation centers. World Vision was also still actively responding to last month’s earthquake in Bohol, which fortunately was not struck by the eye of the storm. Learn more here.

ShelterBox
ShelterBox, an emergency relief organization, provides families with a survival kit that includes a tent and other essential items while they are displaced or homeless. Learn more here.

UNICEF
Anticipating that children will likely be among the worst affected by the typhoon, UNICEF is working on getting essential medicines, nutrition supplies, safe water and hygiene supplies to children and families in the area. Learn more here.

Salvation Army
The Christian hunger and poverty-fighting organization is allocating 100 percent of all disaster donations for relief efforts “to immediately meet the specific needs of disaster survivors.” Text TYPHOON to 80888 to Donate $10 or give online.Learn more here.

Save The Children
The organization, which prioritizes kids’ needs, has sent relief kits for children and families, including household cleaning items, temporary school tents and learning materials. Learn more here.

Operation USA
The Los Angeles-based nonprofit is sending much-needed water purification supplies to victims and seeking corporate partners to help with delivery. Donate $10 by texting AID to 50555 or give online. Learn more here.

American Jewish Joint Distribution Committee
The humanitarian assistance organization, which fights global poverty in 70 different countries, is sending disaster and relief development experts to aid in recovery. The organization is also empowering local partners in their efforts.Learn more here.

The Lutheran World Relief
LWR, which fights poverty by improving global health and ensuring basic human rights are met, is working with local partners to provide water, shelter, financial resources and recovery efforts. LWR is appealing for $2.5 million for its typhoon relief fund. Learn more here.

Team Rubicon
The nonprofit, which galvanizes first responders and veterans to help in times of crises, has sent a group of specialists to aid in search-and rescue, medical triage and medical relief. A second team will be deployed Nov. 12 to create a supply chain for field work. Learn more here.

Your Online Image: Policy From the ACP

Introduction

A new policy statement from the American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB)[1] takes a closer look at online patient/physician relationships in social media and other “Web 2.0” interactions. The policy does not address or examine telemedicine, e-prescribing or e-diagnosing, or electronic health record issues.

The study is published in Annals of Internal Medicine, but how appropriate that the paper made its debut at a site close to Silicon Valley.[1]

“You” Online

An online presence is becoming essential for health professionals. When is the last time you used a phone book to find a phone number or location? With smartphones getting smarter and tablets getting faster (and smaller), we all want access to information at our fingertips and on demand.

Just about everyone uses the Internet as their information source. Patients use it as a source of medical information. Physicians use it to stay current with the latest medical advances. In fact, a Pew Internet survey ranked seeking health information as the third most popular online activity.[2]

Staying connected is now an engrained part of our culture. Networking sites, media-sharing sites, and blog platforms have increased in popularity. But the introduction of social media is also changing the rules. The physician/patient interface is now a little more complicated. This policy paper sets some guidelines to make sure you don’t cross the line.

Connectivity — Without Crossing the Line

The policy paper includes a quick-look table matching available online activities with potential pitfalls and providing recommended safeguards. It’s a must-read. Protecting patient confidentiality and preserving trust are essentials for a positive patient/physician relationship.

Pitfalls of Texting

The policy paper also discusses the pitfalls of texting with immediate expectations. Text messages are short and quick. Some pharmacies and insurers are piloting their use for pharmacy refills and appointments. Security and confidentiality are valid concerns. These technologies also present unintended expectations of immediate access (and answers). The truncated format limits detailed explanation and could increase odds that the message could be misconstrued. These reasons are why the policy paper cautions against routine texting for medical interactions — even for established patients.

Do a self online audit. Find out what others are reading about you. The policy paper recommends doing this routinely and correcting inaccurate information. Unfortunately, they give no specifics as to how to accomplish the goal of rectifying mistakes and inaccuracies in what others have posted.

The paper does suggest a possible remedy for mitigating misrepresentations on physician ranking Websites. Although there is no way to have these deleted, the paper proposes establishing a professional profile “so that it ‘appears’ first during a search” as a means of controlling what patients read.

Pause Before Posting

Carefully consider the content of what you post. Because postings on the Internet are archived, they are essentially permanent. That’s why reflecting before reacting is a good idea.

Online perceptions include not only what is written about you, but also photos. Provocative or inappropriate postings indicate poor judgment and adverse consequences, including medical board complaints.

ACP and FSMB also advise against “airing frustrations” and “venting” in online forums. Such postings can be misconstrued and can come back to haunt you!

Know the Rules, and Follow Them

When transferring patient information electronically, be sure to stay compliant with the Health Insurance Portability and Accountability Act (HIPAA). Patients should also be made aware of the inherent security risks in communicating via email.

Some states’ laws (for example those in Hawaii) do not require a preexisting relationship for emailing between patients and physicians, a practice that is not supported by ACP or the FSMB. The policy paper also points out that some state medical boards consider emailing a violation if the physician is not licensed in the state in which the electronic communication is received. No source or specific examples were given, however.

To Friend or Not to Friend? Setting Personal/Professional Boundaries

The policy gives guidance for responding to online “friend” requests from patients: Don’t do it. The position paper specifically discourages “friending” patients on personal social media sites, such as Facebook. This blurs patient/physician boundaries.

Information from Industry

Having a separate personal and professional online presence can help mitigate this problem. It is acceptable to use professional profiles in networking and community outreach.

Patient-targeted Googling also raises red flags: “curiosity, voyeurism, and habit.” This type of digital tracking could undermine trust in the patient/physician relationship.

Final Words: Online Professionalism Is Paramount

Physicians are professionals. One of the premises of being a professional is that the public expects us to self-regulate. This policy paper provides a good starting point for online relationship discussions. These premises also apply to physicians in training. The authors acknowledge that this policy is a starting point in dialogue and will require more fine-tuning as physicians and patients navigate the online terrain.

TUCSON, Ariz., April 24, 2013 /PRNewswire-USNewswire/ –The Association of American Physicians & Surgeons (AAPS) has filed suit today in federal court against the American Board of Medical Specialties (ABMS) for restraining trade and causing a reduction in access by patients to their physicians. The ABMS has entered into agreements with 24 other corporations to impose enormous “recertification” burdens on physicians, which are not justified by any significant improvements in patient care.

ABMS has a proprietary, trademarked program of recertification, called the “ABMS Maintenance of Certification®” or “ABMS MOC®,” which brings in many tens of millions of dollars in revenue to ABMS and the 24 allied corporations. Though ostensibly non-profit, these corporations then pay prodigious salaries to their executives, often in excess of $700,000 per year. But their recertification demands take physicians away from their patients, and result in hospitals denying access by patients to their physicians.

In a case cited in this lawsuit,a first-rate physician in New Jersey was excluded from the medical staff at a hospital in New Jersey simply because he had not paid for and spent time on recertification with one of these private corporations. He runs a charity clinic that has logged more than 30,000 visits, but now none of those patients can see him at the local hospital because of the money-making scheme of recertification.

There is a worsening doctor shortage in the United States, such that the average physician has the time to spend only 7 minutes with each patient. Roughly half the counties in our nation lack a single OB/GYN physician to care for women. There are long delays to see primary care physicians in Massachusetts, and about half of them are not even taking new patients.

Money-making schemes that reduce access by patients to patients, as “maintenance of certification” does, are against public policy and harmful to the timely delivery of medical care. AAPS’s lawsuit states, “There is no justification for requiring the purchase of Defendant’s product as a condition of practicing medicine or being on hospital medical staffs, yet ABMS has agreed with others to cause exclusion of physicians who do not purchase or comply with Defendant’s program.” AAPS adds that ABMS’s “program is a moneymaking, self-enrichment scheme that reduces the supply of hospital-based physicians and decreases the time physicians have available for patients, in violation of Section 1 of the Sherman Act.”

ABMS does the public an additional disservice by inviting patients to search on which physicians have “recertified” and which ones have not, despite the lack of evidence that there is any difference in malpractice rates between the two categories. ABMS should try to make money by helping patients, rather than disparaging the many thousands of good physicians who spend their time caring for patients rather than on ABMS’s self-serving recertification scheme.

A recent survey by AAPS showed that only 9.5% of 167 respondents thought that “maintenance of certification is good; we should support it.” In anearlier survey, only 22% of physicians who had been through the process said they would voluntarily do it again.

AAPS’s lawsuit, which was filed today in Trenton, New Jersey, seeks declaratory and injunctive relief to enjoin ABMS’s continuing violations of antitrust law and misrepresentations about the medical skills of physicians who decline to purchase and spend time on its program. AAPS also seeks a refund of fees paid by its members to ABMS and its 24 other corporations as a result of ABMS’s conduct.

Can “workplace stress” be defined?

We hear a lot about stress, but what is it? Taber’s Cyclopedic Medical Dictionary defines stress as “the result produced when a structure, system or organism is acted upon by forces that disrupt equilibrium or produce strain”. In simpler terms, stress is the result of any emotional, physical, social, economic, or other factors that require a response or change. It is generally believed that some stress is okay (sometimes referred to as “challenge”or “positive stress”) but when stress occurs in amounts that you cannot handle, both mental and physical changes may occur.

“Workplace stress” then is the harmful physical and emotional responses that can happen when there is a conflict between job demands on the employee and the amount of control an employee has over meeting these demands. In general, the combination of high demands in a job and a low amount of control over the situation can lead to stress.

Stress in the workplace can have many origins or come from one single event. It can impact on both employees and employers alike. As stated by the Canadian Mental Health Association:

Fear of job redundancy, layoffs due to an uncertain economy, increased demands for overtime due to staff cutbacks act as negative stressors. Employees who start to feel the “pressure to perform” can get caught in a downward spiral of increasing effort to meet rising expectations with no increase in job satisfaction. The relentless requirement to work at optimum performance takes its toll in job dissatisfaction, employee turnover, reduced efficiency, illness and even death. Absenteeism, illness, alcoholism, “petty internal politics”, bad or snap decisions, indifference and apathy, lack of motivation or creativity are all by-products of an over stressed workplace.

I have heard stress can be both good and bad. Is this true?

Some stress is normal. In fact, it is often what provides us with the energy and motivation to meet our daily challenges both at home and at the workplace. Stress in these situations is the kind that helps you “rise” to a challenge and meet your goals such as deadlines, sales or production targets, or finding new clients. Some people would not consider this challenge a type of stress because, having met the challenge, we are satisfied and happy. However, as with most things, too much stress can have negative impacts. When the feeling of satisfaction turns into exhaustion, frustration or dissatisfaction, or when the challenges at work become too demanding, we begin to see negative signs of stress.

What are examples of things that cause stress at the workplace?

In the workplace, stress can be the result of any number of situations. Some examples include:

Categories of Job Stressors

Examples of Sources of Stress

Factors unique to the job

workload (overload and underload)

pace / variety / meaningfulness of work

autonomy (e.g., the ability to make your own decisions about our own job or about specific tasks)

Can stress cause health effects?

Yes, stress can have an impact on your overall health. Our bodies are designed, pre-programmed if you wish, with a set of automatic responses to deal with stress. This system is very effective for the short term “fight or flight” responses we need when faced with an immediate danger. The problem is that our bodies deal with all types of stress in the same way. Experiencing stress for long periods of time (such as lower level but constant stressors at work) will activate this system, but it doesn’t get the chance to “turn off”. The body’s “pre-programmed” response to stress has been called the “Generalized Stress Response” and includes:

Interpretation of your score (based on the number of “Yes” selections):

0-5: There are few hassles in your life. Make sure though, that you are not trying to deliberately avoid problems.

6-10: You’ve got your life in fairly good control. Work on the choices and habits that could still be causing you some unnecessary stress in your life.

11-15: You are approaching the danger zone. You may be suffering stress-related symptoms and your relationships could be strained. Think carefully about choices you’ve made and take relaxation breaks every day.

16-25: Emergency! It is critical that you stop and re-think how you are living; change your attitudes and pay careful attention to diet, exercise and relaxation.

Do all of these signs or symptoms happen all at once and what level of help should be sought?

No, not normally. The signs and symptoms from stress tend to progress through several phases or stages. The phases can be described as below:

Phase

Signs/Symptoms

Action

Phase 1 – Warning
Early warning signs are often more emotional than physical and may take a year or more before they are noticeable.

feelings of vague anxiety

depression

boredom

apathy

emotional fatigue

talking about feelings

taking a vacation

making a change from regular activities

taking time for yourself

Phase 2 – Mild Symptoms
Warning signs have progressed and intensified. Over a period of 6 to 18 months, physical signs may also be evident.

sleep disturbances

more frequent headaches/colds

muscle aches

intensified physical and emotional fatigue

withdrawal from contact with others

irritability

intensified depression

more aggressive lifestyle changes may be needed.

short-term counseling

Phase 3 – Entrenched Cumulative Stress
This phase occurs when the above phases continue to be ignored. Stress starts to create a deeper impact on career, family life and personal well-being.

increased use of alcohol, smoking, non-prescription drugs

depression

physical and emotional fatigue

loss of sex drive

ulcers

marital discord

crying spells

intense anxiety

rigid thinking

withdrawal

restlessness

sleeplessness

The help of medical and psychological professionals is highly recommended.

Phase 4 – Severe/ Debilitating Cumulative Stress Reaction
This phase is often considered “self-destructive” and tends to occur after 5 to10 years of continued stress.

What are some general tips for dealing with stress at the workplace?

Since the causes of workplace stress vary greatly, so do the strategies to reduce or prevent it.

Where stress in the workplace is caused, for example, by a physical agent, it is best to control it at its source. If the workplace is too loud, control measures to deal with the noise should be implemented where ever possible. If you are experiencing pain from repetitive strain, workstations can be re-designed to reduce repetitive and strenuous movements. More detailed information and suggestions are located in the many other documents in OSH Answers (such as noise, ergonomics, or violence in the workplace, etc.) or by asking the Inquiries Service.

Job design is also an important factor. Good job design accommodates an employee’s mental and physical abilities. In general, the following job design guidelines will help minimize or control workplace stress:

the job should be reasonably demanding (but not based on “sheer endurance”) and provide the employee with at least a minimum of variety in job tasks

the employee should be able to learn on the job and be allowed to continue to learn as their career progresses

the job should comprise some area of decision-making that the individual can call his or her own.

there should be some degree of social support and recognition in the workplace

the employee should feel that the job leads to some sort of desirable future

What can the employer do to help?

Employers should assess the workplace for the risk of stress. Look for pressures at work which could cause high and long lasting levels of stress, and who may be harmed by these pressures. Determine what can be done to prevent the pressures from becoming negative stressors.

Employers can address stress in many ways.

DO

Treat all employees in a fair and respectful manner.

Take stress seriously and be understanding to staff under too much pressure.

Be aware of the signs and symptoms that a person may be having trouble coping with stress.

Involve employees in decision-making and allow for their input directly or through committees, etc.

Encourage managers to have an understanding attitude and to be proactive by looking for signs of stress among their staff.

Provide workplace health and wellness programs that target the true source of the stress. The source of stress at work can be from any number of causes – safety, ergonomics, job demands, etc. Survey the employees and ask them for help identifying the actual cause.

Design jobs to allow for a balanced workload. Allow employees to have control over the tasks they do as much as possible.

Value and recognize individuals’ results and skills.

Provide support. Be clear about job expectations.

Keep job demands reasonable by providing manageable deadlines, hours of work, and clear duties as well as work that is interesting and varied.

Provide access to Employee Assistance Programs (EAPs) for those who wish to attend.

DO NOT

Do not tolerate bullying or harassment in any form.

Do not ignore signs that employees are under pressure or feeling stressed.

Do not forget that elements of the workplace itself can be a cause of stress. Stress management training and counselling services can be helpful to individuals, but do not forget to look for the root cause of the stress and to address them as quickly as possible.

Is there anything I can do to help myself deal with the stress I am experiencing at work?

In many cases, the origin of the stress is something that cannot be changed immediately. Therefore, finding ways to help maintain good mental health is essential. There are many ways to be proactive in dealing with stress. In the workplace, you might try some of the following as suggested by the Canadian Mental Health Association:

Learn to relax, take several deep breaths throughout the day, or have regular stretch breaks. Stretching is simple enough to do anywhere and only takes a few seconds.

Take charge of your situation by taking 10 minutes at the beginning of each day to priorize and organize your day. Be honest with your colleagues, but be constructive and make practical suggestions. Be realistic about what you can change.

Are there organizations that can help?*

Yes, there are many. Your family doctor can often recommend a professional for you. Other examples include the Employee Assistance Programs (EAP) or associations such as the Canadian Mental Health Association (CMHA) or the Canadian Centre on Substance Abuse (CCSA) to name just a few.

EAP programs are confidential, short term, counselling services for employees with problems that affect their work performance. The services of EAP providers are often purchased by your company. Check with your human resources department (or equivalent) for contact information.

CMHA ‘s programs are meant to ensure that people whose mental health is endangered will find the help needed to cope with crisis, regain confidence, and return to community, family and job.

(*We have mentioned these organizations as a means of providing a potentially useful referral. You should contact the organization(s) directly for more information about their services. Please note that mention of these organizations does not represent a recommendation or endorsement by CCOHS of these organizations over others of which you may be aware.)

Give yourself permission to take a break from your worries and concerns. Recognize that dedicating even a short time every day to your mental fitness will reap significant benefits in terms of feeling rejuvenated and more confident.

“Collect” positive emotional moments – Make a point of recalling times when you have experienced pleasure, comfort, tenderness, confidence or other positive things.

Do one thing at a time – Be “present” in the moment, whether out for a walk or spending time with friends, turn off your cell phone and your mental “to do” list.

Enjoy hobbies – Hobbies can bring balance to your life by allowing you to do something you enjoy because you want to do it.

Set personal goals – Goals don’t have to be ambitious. They could be as simple as finishing a book, walking around the block every day, learning to play bridge, or callingyour friends instead of waiting by the phone. Whatever goal you set, reaching it will build confidence and a sense of satisfaction.

Express yourself – Whether in a journal or talking to a wall, expressing yourself after a stressful day can help you gain perspective, release tension, and boost your body’s resistance to illness.

Laugh – Laughter often really is the best medicine. Even better is sharing something that makes you smile or laugh with someone you know.

Treat yourself well – Take some “you” time – whether it’s cooking a good meal, having a bubble bath or seeing a movie, do something that brings you joy.

There will not be enough emergency medicine residency trained physicians to cover our nation’s emergency departments for many years. (Acad Emerg Med 2008;15[12]:1317.) This shortage is even more pronounced in smaller and rural EDs and in the face of continually increasing demand for emergency care.

So who covers these EDs? In 2008, 31 percent of physicians practicing in EDs — more than 12,000 physicians — were not emergency medicine residency trained or emergency medicine board certified. (Ann Emerg Med 2009;54[3]:349.) They are family physicians, internists, surgeons, and pediatricians who provide emergency care when an emergency medicine-trained physician is not available. This emergency medicine workforce shortage was a major topic of the 2009 Future of Emergency Medicine Summit, which brought together representatives of the leading emergency medicine organizations. (Schneider SM, et al. The future of emergency medicine. Ann Emerg Med 2010; in press.) Numerous potential solutions were discussed, including increasing emergency medicine residency slots, loan repayment for emergency physicians, joint emergency medicine-family medicine training, and using scribes to improve efficiency. One recommendation that has become increasing popular is the use of midlevel providers such as physician assistants and nurse practitioners.

Indeed, the introduction of midlevel providers to emergency care is already occurring in great numbers. In 2005, 13 percent of all U.S. ED visits were covered by a midlevel provider, up from only four percent in 1993. (Am J Emerg Med 2010;28[1]:90.) At first glance, this may seem like a win-win scenario. Midlevel providers help expand the efficiency of emergency physicians, and cover some of the workforce gap. Their cost to the hospital is lower than a physician’s, and at least for minor presentations, patient satisfaction appears to be high. (Am J Emerg Med 2000;18[6]:661.) An increasing scope of practice and level of autonomy, however, calls into question whether midlevel providers are collaborating with emergency physicians or actually replacingthem.

We fully support emergency medicine residency training, and believe that emergency medicine board certified physicians are the gold standard for providers in the ED. When emergency medicine-trained physicians are unavailable or unwilling to cover some EDs, such as smaller and rural EDs, however, many non-emergency medicine-trained providers, both physicians and midlevel providers, continue to fill the void. While physicians attract a greater amount of criticism and scrutiny, midlevel providers, who do not have formal emergency medicine training and fewer overall years of medical training than physicians, are often embraced as a solution to the workforce shortage.

While NPs are licensed to practice independently in some states, PAs must collaborate with physicians. The scope of practice and degree of autonomy for both groups is state-dependent. Neither group has developed accredited emergency medicine training programs for specialization in emergency care. Yet independent practice is becoming increasingly common. (See figure.) In paging through ED job announcements, we have encountered postings that state, “We are currently seeking a PA who is comfortable working autonomously in our ED.” In 2005, five percent of all ED visits nationwide were seen by midlevel providers without onsite physician involvement, up from one percent in 1993. (Am J Emerg Med 2010;28[1]:90.)

But indirect physician supervision of PAs and their independent practice is legal, isn’t it? Supervision and scope of practice for midlevel providers are defined at the state level. Most states allow provision of emergency care and define supervision as the availability of a physician, but participation in care or even physical presence in the facility is often not required. Physician supervision by co-signing charts or prescriptions days to weeks after the ED visit is occurring throughout the country, although it is unknown how widespread this practice is. How much oversight is truly being provided for these patients?

But isn’t this is only an issue for rural EDs, where any provider is better than no provider? Not really. National data show that 86 percent of midlevel provider visits without physician involvement are in urban EDs. (Am J Emerg Med 2010;28[1]:90.) While the number of these visits has remained stable in rural EDs, they have markedly increased in urban EDs over the past decade. Emergency physician workforce shortages are probably not driving this as much as practical and financial considerations; ED administrators may hire less expensive midlevel providers instead of emergency physicians. With emergency medicine residency graduates having difficulty obtaining jobs in some desirable urban markets, it’s possible midlevel providers may actually be taking jobs away from emergency medicine residents rather than solving the emergency medicine workforce shortage and maldistribution.

What about acuity? Midlevel providers don’t really need a physician to directly supervise the care of patients with obvious ankle sprains and minor lacerations. This may be true, and data support the quality of care by independent midlevel provider care for minor ED presentations. (Lancet 1999;354 [9187]:1321.) Of ED patients seen in 2005 by midlevel providers without direct physician supervision, however, six percent arrived by ambulance, 37 percent had urgent/emergent acuity, and three percent were admitted to the hospital. (Am J Emerg Med2010;28[1]:90.) While these acuity data are lower than those for physicians in the ED, the role of midlevel providers, who may practice without on-site physician involvement, has clearly extended beyond minor presentations.

The latter groups, in which physicians were directly involved, provided care of similar quality. While this is a single study of one condition, acute asthma care has well-defined treatment pathways and evidence-based national guidelines that should create more uniform care than other acute conditions. These data support a view that midlevel providers should collaborate with, rather than replace, emergency physicians, especially for higher acuity patients.

Midlevel providers have a major role in U.S. emergency care, and we support efforts to develop emergency medicine training, accreditation, and continuing medical education for PAs and NPs. Indeed, there are now several post-graduate emergency medicine training programs for PAs and NPs. Before moving forward with a midlevel provider-based “solution” to the emergency physician workforce shortage, we encourage more thoughtful discussion about training, scope of practice, and supervision. The growing acceptance of non-emergency medicine-trained midlevel providers practicing independently in EDs is difficult to reconcile with the often heated and absolute opposition to non-emergency medicine residency trained physicians. The ultimate goal of most emergency physicians and midlevel providers, regardless of their emergency medicine training and accreditation, is to provide effective and safe care for our patients. This should stay at the forefront of the emergency medicine workforce debate.

A National Study Examining Emergency Medicine Specialty Training and Quality Measures in the Emergency Department.

Abstract

The objective of this study was to measure the relationship between emergency medicine (EM) specialty training and quality measures in the emergency department (ED). Data were gathered from the 2003-2004 National Hospital Ambulatory Medical Care Survey. The outcome was proportion of patients with acute myocardial infarction (AMI), pneumonia (PNA), and long-bone fracture (LBF) who received recommended therapy. These measures were analyzed with respect to EM residency completion. Compared with EDs with more than 80% EM-trained physicians, EDs with fewer than 80% EM-trained physicians had similar rates of aspirin (43% vs 42%) and beta-blocker (26% vs 19%) use for AMI, appropriate antibiotics (78% vs 83%) and pulse oximetry (51% vs 55%) for PNA, and analgesia (85% vs 79%) for LBF. Additionally, a composite end point and an adjusted model showed no statistical difference across these measures. The proportion of residency-trained EM physicians did not affect the use of recommended treatment for AMI, PNA, and LBF.

“When patients present to the emergency department (ED) for care, they assume that they will be cared for by a physician qualified to diagnose and treat their ills. This trust is even more sacred in emergency settings because patients with emergent conditions generally do not have the opportunity to choose the location or provider who will render this care. For this reason, the American College of Emergency Physicians and the American Board of Emergency Medicine advocate specific training (ie, emergency medicine [EM] residency) for physicians who treat patients in EDs.

Yet across the United States, only 69% of physicians who work in the ED are EM residency trained or EM board certified. Fewer than 40% of EDs have a majority of physicians with EM residency training, and only 1 state (Hawaii)adequate supply of EM-board-certified emergency physicians.

Although recent EM physicians are much more likely to be EM residency trained, this deficiency has been attributedto at least 4 different causes: (1) overall shortage of EM-trained physicians; (2) because EM is a relatively young specialty, a significant proportion of the workforce is composed of so-called legacy emergency physicians (ie, those engaged in EM practice prior to the proliferation of EM specialty training programs); (3) the lower staff cost of hiring non-EM-trained physicians; and (4) the difficulty of recruiting specialty trained physicians to rural locations. This variability in training of ED physicians has elicited some controversy, but the impact of the differences in training on clinical outcomes has not been assessed. EM-trained physicians are less likely to have expensive malpractice claims against them compared with their non-EM-trained counterparts.

Whether specialty training when compared to care provided by generalists leads to improved clinical outcomes for specific conditions has been reviewed more broadly in medicine, but not in the context of EM.

Because the Institute of Medicine’s 1999 report identified shortcomings in the quality of care in the US health system, there has been renewed emphasis on emphasis on identifying measures of quality and performance.

Treatment of acute myocardial infarction (AMI), pneumonia (PNA), and long bone fractures (LBFs) has been used to evaluate quality across EDs. These characteristics have been recognized as ED quality measures to varying extents. These measures evaluate the extent to which patients receive recommended therapies.”

Commentary:

Core Measures are a set of care processes developed by The Joint Commission, the nation’s predominant standards-setting and accrediting body in health care, to improve the quality of health care by implementing a national, standardized performance measurement system. The Core Measures were derived largely from a set of quality indicators defined by the Centers for Medicare and Medicaid Services (CMS). They have been shown to reduce the risk of complications, prevent recurrences and otherwise treat the majority of patients who come to a hospital for treatment of a condition or illness. Core Measures help hospitals improve the quality of patient care by focusing on the actual results of care.

This study was a national cross-sectional study of ED visits for 2003 through 2004 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NHAMCS is administered by the Centers for Disease Control and Prevention’s NCHS and is endorsed by the Emergency Nurses Association, the Society for Academic Emergency Medicine, the American College of Emergency Physicians, and the American College of Osteopathic Emergency Physicians.It is a national probability sample of visits to the EDs of non-governmental general and short-stay acute care hospitals located in the 50 states and the District of Columbia.

As stated above, this study was performed using cross-sectional data culled from a national database of all 50 states, and is clearly of greater quality and inspires more confidence compared to the small studies often cited to support claims of the alleged superior skills of EM residency trained physicians over their experienced, non-EM residency trained ER colleagues ( AAEM: Board Certification, Articles on Quality of Care ). Aside from having small samples, these other studies were performed with less stringent methodologies (mostly retrospective reviews) performed in only one hospital or at most, compare one hospital with another, mostly examining the effects of the introduction of an ER residency training program, the results of which can not, by any stretch of the imagination, be extrapolated to demonstrate what the AAEM and ABEM claim, that EM residency trained physicians have significantly superior clinical outcomes compared with non-EM residency trained physicians.

This quality study shows otherwise. In the discussion, it is interesting to note that the authors are hesitant to state outright what their results show, namely that when looking at nationally defined clinical criteria, non-EM residency trained and EM residency trained physicians give the same quality care. Instead, they state that the measures they used

“may be too simple to demonstrate the value of EM physicians. Future efforts to assess the role of EM training in ED quality should focus more on measures that demonstrate the unique skills of EM-trained physicians.”

What “unique skills”? The authors themselves admit that they chose these measures based on quality studies endorsed by professional societies. What the authors may be hesitant to acknowledge due to the controversy currently raging in the EM community, is that there is no significant difference in quality between EM residency trained physicians and experienced non-EM residency trained physicians, certainly not enough to warrant paying non-EM residency trained physicians much less and removing their much needed presence in the ERs.